52IMPLEMENTING HOSPITAL ANTICIPATORY CARE PLANNING IN ACUTE ORTHOPAEDIC WARDS - A QUALITY IMPROVEMENT PROJECT

Abstract

Introduction: Up to 50% patients with neck of femur (NoF) fractures are deceased at one year. Mortality is only partly attributable to fracture, with frailty and co-morbidities conferring significant risk. Hospital Anticipatory Care Planning (HACP) is designed to guide interventions if patients deteriorate. It aligns well with the goals of Realistic Medicine, promoting individualised, patient-centred care to minimise harm and avoid futile treatment. Aim(s): To assess application of HACP in elderly patients with NoF fracture in an acute Orthopaedic ward in University Hospital Wishaw and promote sustained improvement. Method(s): We prospectively collected audit data between January and October 2018. Patients aged over 65 with NoF fractures were identified. Case notes were reviewed regarding completion and documentation of HACP and resuscitation status. Mortality rates were reviewed at three months. PDSA methodology was applied. We conducted the following interventions: 1. Audit data presented at regional orthopaedic education meeting 2. Individualised, anonymous feedback on HACP completion to each Orthopaedic consultant, following local agreement. Result(s): Initial data showed that 21% patients had a HACP in place; 8% were fully complete. 8% patients had an isolated DNACPR form. Documentation of HACP-related discussions with patients/families was poor. 23% patients were deceased at three month follow-up. Following intervention, 29% patients had a HACP in place; 21% were fully complete. All patients with DNACPR forms in place had a coexisting HACP and all discussions were documented. An interval cycle at four months demonstrated consistent results and thus, sustained improvement. Discussion(s): The results of our quality improvement project showed that with education, incentivised and individualised feedback, the use of completed and discussed HACP in patients with fractured NoF improved. HACP should complement DNACPR. Ongoing actions involve working alongside the Acute Care of Elderly nurses within Orthopaedics, to embed and maintain the use of HACP in frail, vulnerable patients.